The editors asked several experts to share their perspectives on the crisis in U.S. primary care. Their articles, which address this crisis from six different angles, follow. We also brought the five U.S. contributors together for a roundtable discussion of the problems and potential solutions for training, practice, compensation, and systemic change. A video of the discussion and reader comments can be seen at http://www.nejm.org.
Primary care has been one of the best jobs in medicine, and it can be again. In fact, primary care must recapture its attraction for the next generation’s best trainees — or the chaos and inefficiency of U.S. health care will only worsen.
The challenges are formidable, for there are so many reasons for young physicians to go into other fields. Many physicians graduate from medical school with staggering debts, and procedure-oriented specialties offer higher potential incomes. The work of primary care is itself overwhelming. Primary care physicians often go home worried that they may have made mistakes, or dispirited because they did not complete their work.
But as Treadway’s story reminds us, failure is not an option. Throughout their lives, but particularly at the end, patients want and need physicians who focus on the people who have diseases, not just the diseases that they have.
And when people want and need something, the market usually gives it to them. Right now, patients throughout the UnitedStates are having difficulty finding primary care physicians, so incomes for such practitioners will probably rise as health care organizations struggle to meet the demand for primary care. At the delivery system where I work, we are actively discussingquestions such as how high primary care salaries need to be, where the money to pay them will come from, and how quicklyhigher incomes might work to expand the primary care pipeline.
These questions are difficult to answer, because money is only part of the problem and therefore can be only part of the solution. We have to figure out how to make the job of primary care doable once again. We have to learn how to surround primary care physicians with teams that help them care for their populations of patients, as Bodenheimer argues in his article, and we have to equip them with systems such as electronic medical records to help them manage the flood of information that moves through their offices every day. And, as Goroll suggests in his article, we have to develop payment policies that make these innovations sustainable.
Many organizations have found that when they increase payments to primary care physicians, the physicians respond by reducing the number of patients they see. These physicians, it turns out, place a higher priority on trying to do a good job andhaving a sane life than on making a higher income. The message they’re sending is that more money will not be enough to revitalize primary care.
Revitalization will take something more like reinvention, and it will demand creativity and flexibility from all parties — including primary care physicians themselves. These physicians need to learn to work in teams and adjust to the notion that much of primary care can be delivered by nonphysician team members, some of whom are located in nontraditional settings, such aslimited-service clinics in retail stores.
In this collection of articles, Starfield describes some of the major policy issues that must be addressed as the U.S. health care system develops a stronger primary care focus, and Roland suggests that there are some features of primary care in the United Kingdom that might warrant adaptation. As we test new concepts in the years ahead, primary care will undoubtedly changedramatically. But if we are successful and wise, these changes should allow key aspects of being a primary care physician toremain the same.
Primary care doctors should once again feel a deep sense of satisfaction when they leave their offices or patients’ homes after helping people through difficult times. They should be able to leave work thinking not of their income, or of unanswered phone calls, or of test results that they might have overlooked. They should go home thinking, “This is what I was meant to do.”
No potential conflict of interest relevant to this article was reported.
Dr. Lee is network president at Partners HealthCare System, Boston, and an associate editor of the Journal.